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Classifiedintofourdegreesdependentontissueinvolvement:

Firstdegree: skin/vaginal mucosa only (does not require repair if the skinedges are well

opposed)

Seconddegree:skin,vaginalmucosa,andperinealmusclesbutnottheanalsphincter

Thirddegree:tearinvolvingtheanalsphinctercomplex

3A:<50%ofexternalanalsphinctercomplextorn 3B:>50%ofexternalanalsphinctercomplextorn 3C:internalanalsphinctertorn

Fourthdegree:tearinvolvinganalepithelium±analsphinctercomplex(externalandinternal

analsphincter) An episiotomyis indicatedfor instrumental birth and/or suspected fetal compromise. This is an iatrogenicsecond-degreetraumaoriginatingfromvaginalfourchetteandismediolateralatanaxis of45–60°(usuallytowardstheright) Repairshouldbecarriedoutassoonaspossibleafterbirthtominimizetheriskofinfectionand bloodloss.Useappropriatelocalorregionalanaesthetic Third- andfourth-degree tearsshouldberepaired intheatreandpatientsshouldreceivea 7-day course of antibiotics. They should also be discharged with laxatives and should receive appropriatephysiotherapyreviewandfollow-up Thepatientshould be givenadviceregarding hygieneandwoundcareand thewoundshouldbe reviewed prior todischarge.Patientsshouldreceive safetynetadvice toseekmedicaladviceif theyexperienceanysignsofinfection.

Furtherreading

1.GeekyMedics.HowtoreadaCTG.Availableat:https://geekymedics.com/how-to-read-a-ctg/

2. RCOG. Assessment of fetal wellbeing. Available at: https://elearning.rcog.org.uk/assessment-fetal-

wellbeing/assessment-fetal-wellbeing

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Chapter63

Nauseaandvomitinginpregnancy

Guideline: RCOG GTG69 (The management of nausea and vomiting of

pregnancy and hyperemesis gravidarum):

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg69/

OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Nausea and vomiting in pregnancy (NVP) is a common reason for hospitalattendance and admission inthe pregnantwoman. About80%of pregnant women willexperience thesesymptomsalthough90%ofcasesresolveby20weeks.WhenNVPissevere,itmay satisfy the criteria to be termed hyperemesis gravidarum (HG) (see later in chapter). Womenwithmultipleortrophoblasticpregnanciesareat↑risk;however,themajorityof patientswillhaveasingletonpregnancy.

Diagnosis

Diagnosis is in the first trimester. Typical onset is at approximately 4–7 weeks with symptoms usually peakingat9weeks.Other causes ofnauseaand vomitingneedtobe excluded,particularlyifpresenting>10+6weeks.

Differentialdiagnosis

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Acuteabdomen:cholecystitis,pancreatitis,appendicitis,bowelobstruction Gastrointestinal:pepticulcer,gastroenteritis,hepatitis Endocrine:diabeticketoacidosis,hypothyroidism Urinary:UTI,pyelonephritis Other:druginduced.

History

Protractednauseaand/orvomiting Inabilitytotoleratefood/fluids Dehydration Hypersalivation Weightloss(>5%frompre-pregnancy) Haematemesis(secondarytoMallory–Weisstears).

Historytoexcludeothercauses:

Abdominalpain Fevers Urinary/bowelsymptoms PVloss Drughistory.

SeverityofNVPcanbequantifiedusingthePregnancy-UniqueQuantificationofEmesis (PUQE)index(Table63.1).

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Table63.1Totalscoreissumofrepliestoeachofthethreequestions

Inthelast24hours,howlonghaveyoufeltnauseated? 0

times (1)

1houror less(2)

2–3 hours (3)

4–6 hours (4)

Morethan6 (5)

Inthelast24hours,howmanytimeshaveyouvomited? 0

times (1)

1–2times (2)

3–4 times (3)

5–6 times (4)

7ormore times(5)

Inthelast24hours,howmanytimeshaveyouhad retching/dryheaveswithoutvomiting?

0 times (1)

1–2times (2)

3–4 times (3)

5–6 times (4)

7ormore times(5)

PUQE-24score:mild≤6;moderate=7–12;severe=13–15.

ReprintedfromKorenG,BoskvocicR,HardM,MaltepeC,NaviozY,EinarsonA.Motherisk-PUQE (pregnancy-uniquequantificationofemesisandnausea)scoringsystemfornauseaandvomitingof pregnancy.Americanjournalofobstetricsandgynecology.2002;186:S228–31withpermissionfrom Mosby.

Hyperemesisgravidarum

Thisisatriadof:

>5%pre-pregnancyweightloss Dehydration Electrolyteimbalance.

Examination

Themainfocusshouldbeonperforminganabdominalexamination,andtolookforany clinical signs of dehydration or wasting. Consider a thyroid examination if hypothyroidism/hyperthyroidismisadifferentialdiagnosis.

Investigations

Bedside

Basicobservations Weight Urinalysis(ketonuria,andtoexcludeUTI) MidstreamurinetobesentforMC&S Capillarybloodglucose±bloodketonelevelifdiabetic.

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Bloods

FBC(infection,anaemia,haematocrit) U&E(hyponatraemia,hypokalaemia,renaldisease) Amylase Consider checking TFT (although these may be transiently abnormal due to the biochemical structuralsimilaritybetweenHCGandTSH)andLFTinrefractorycases

Imaging

PelvicUSStoconfirmviabilityandgestationalage(checkfortrophoblastic/multiplepregnancy). This should be arranged as a routine scanunless thepatientis notimproving with treatmentor thereareothermedicalreasonsforanearlierandmoreurgentscan AbdominalUSSmayalsoberequiredifthepatienthassevereabdominalpain OGDmayalsoberequiredifpregnancyseemstobeanunlikelycauseofthesymptoms.

Other

ConsiderscreeningforHelicobacterpyloriifthepatienthassevereabdominalpain.

Management

InitiallyNVPcan bemanagedinthecommunitywithoralantiemetics.Ifthishas failed, ambulatory/daycaremanagementmaybesuitable,particularly forpatientswithaPUQE <13.

Acutemanagement

InpatientadmissionisrequiredifthereiscontinuedNVPwithaninabilitytotolerateoral antiemetics,NVPassociatedwithclinicaldehydration,ketonuria,orweightloss,orNVP associatedwithacomorbiditysuchasaUTI.

Pharmacologicalmanagement

Offer parenteral administration of medications until oral intake is tolerated. Use drugs fromdifferentclassesif the firstchoiceis ineffective.Combinations ofantiemetics may alsoberequired.

Antiemetics

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Firstline—antihistamines/phenothiazines.Thereisnoevidenceofteratogenicity:

Cyclizine:

50mgPO,IM,orIV,TDS

Prochlorperazine:

5–10mgPO,TDS–QDS

12.5mgIM,TDS 25mgrectally,OD

Promethazine:

12.5–25mgPO,IM,IV,orrectally,4–8-hourly

Chlorpromazine:

10–25mgPO,IV,orIM,4–6-hourly 50–100mgrectally,6–8-hourly.

Xonvea® (doxylamine withpyridoxine) is a newer antihistamine-based antiemetic whichis increasingly being offered as an option for patients who do not respond to conservative management.Someprescribers and patients mayprefer this medication as it is specifically licensedforNVP,whereasthisisnotthecasefortraditionalfirst-andsecond-linetreatments.

DiscusswithaseniorobstetricianifXonvea®maybeanoptionlocally.

Secondline—safeandeffective,butsecondlineduetoeithersideeffectsorlimiteddata:

Metoclopramide:

5–10mgPO,IM,orIV,TDS Maximum 5-day course due to possible maternal neurological side effects e.g. extrapyramidalsideeffects,tardivedyskinesia.Contraindicatedinbowelobstruction

Domperidone:

10mgPO,TDS 30–60mgrectally,TDS Maximum7-daycourse,contraindicatedincardiacdisease

Ondansetron:

4–8mgPO,TDS–QDS 8mgIVover15minutes,BD

Thirdline,onseniorobstetricadvice—corticosteroids:

Hydrocortisone100mgIVBD Oncethereisclinicalimprovement,converttoprednisolone50–60mgPOOD,withthedose graduallytapereduntilthelowestmaintenancedosethatcontrolsthesymptomsisreached.

IVrehydration

Normalsalinewith added potassium,e.g.1L0.9%salinewith20mmolpotassium over2hours. Multiplebagswillberequired AvoiddextroseduetotheriskofprecipitatingWernicke’sencephalopathyifthiaminedeficient Fluidstatus should be reassessed after 2Loffluidandthen regularlythereafter.U&Eshould be testeddaily.

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Thiamine

Whenoralintakeisre-established Ifnottoleratinganyoralintake,discusswithaseniorclinicianifPabrinex®shouldbeused.

IfsymptomsofGORD/gastritis

StartPPI/H2receptorantagonist,e.g.omeprazole20mgOD.

VTEprophylaxis

Rememberthatpregnancyisariskfactorfor VTEandthatthisriskisheightenedby dehydration. Unless contraindicated, prescribe LMWH and antiembolic stockings for inpatientswhichmaybestoppedondischarge.

Treatmentafterstabilization

Ifsymptomscontinueintothesecondorthirdtrimester,considerarrangingserialscansto monitorgrowthfrom28weeks.

Specialconsiderations

NVP/hyperemesisgravidarumcanbeextremelyisolatingandcanadverselyaffectqualityoflife. Considermentalhealthstatusinpregnancyandreferforpsychologicalsupportifnecessary.Direct patientstoinformationonlineinordertofeellessisolatedwiththecondition A termination of pregnancy should not be considered for NVP alone until all other treatment optionshavebeentried.ThisisaseniorMDTdecision Complementarytherapies such asginger andacupuncturecanbeeffectiveinsomecasesofmild NVP.

Furtherreading

1.CollinsS,ArulkumaranS,HayesK,etal.(2013).Hyperemesisgravidarum.In:OxfordHandbookof Obstetrics and Gynaecology, 3rd ed (pp. 546–7). Oxford: Oxford University Press. Available at:

https://doi.org/10.1093/med/9780199698400.003.0016

2.PregnancySicknessSupportwebsite.Availableat:https://www.pregnancysicknesssupport.org.uk/

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Chapter64

Pelvicorganprolapseinwomen

Guideline:NICENG123(Urinaryincontinenceandpelvicorganprolapsein

women:management):https://www.nice.org.uk/guidance/ng123

Localtrustguidelines:Pleaserefertoyourlocalguidelinesasnecessary.

Overview

Pelvicorganprolapseoccurswhenoneofthepelvicorgans(bladderorurethra,uterusor vaginal vault, or rectum or bowel) descends beyond the normal anatomical position. Theseconditionsarecommonandcan haveamajorpsychologicaland socialimpacton the patient, leading to severely reduced quality of life. Bladder prolapse is commonly associatedwithurinaryincontinence(seeChapter68).

Diagnosis

History

Ask about onset, duration, and severity of the symptoms. Check coexisting medical conditions and medications. Consider using a validated pelvic floor symptoms questionnaire.

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Urinarysymptoms:

Frequency(>4–7voids/day) Dysuria Haematuria Nocturiaornocturnalenuresis Urgency Voiding difficulties: hesitancy, straining, slow or intermittent stream, needing to change positionorreduceprolapsemanuallytovoidcompletely Postmicturitionsymptoms:feelingofincompleteemptying,terminaldribble Bladderorurethralpain Incontinence(seeChapter68)

Rectalsymptoms:

Constipation,needingtostrainorrequiringdigitalevacuationtopassstool Urgencyorincontinenceofflatusorstool

Vaginalsymptoms:

Dyspareunia Sensationofpressureorheaviness Difficultyusingtampons.

Redflags

New-onseturinaryincontinence or retention, or faecalincontinence along with acute neurological symptoms, or new or changed back pain, are  for cauda equina syndrome.

Examination

Abdominalexamination(excludepelvicmass,retention). Pelvicexamination:

Skinassessment(atrophy,erythema,oedema) Assessmentofurethral/bladderdescentonstraining Presenceanddegree ofprolapse (Table64.1). Ifthe examination findings do notmatch the symptoms,re-examinewhilststanding,squatting,oratanothertime Digitalvaginalexamassessingpelvicfloormusclecontraction Digitalrectalexamassessingtone/voluntarycontractionifthereareneurologicalsymptoms.

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Table64.1Gradingofurogenitalprolapse(Baden–Walkerclassification)

Firstdegree Lowestpartofprolapsedescendshalfwaydownvaginalaxistotheintroitus

Seconddegree Lowestpartofprolapseextendstotheleveloftheintroitusandthroughtheintroitusonstraining

Thirddegree Lowestpartofprolapseextendsthroughtheintroitusandliesoutsidethevagina

Procidentiadescribesathird-degreeuterineprolapse

Investigations

Bedside

WeightandBMI.

Chronicmanagement

Management is dependent on patient preferences, comorbidities, and desire for childbearing.

Lifestyleandsimpleinterventions

Weightloss(ifBMI>30kg/m2) Preventingand/ortreatingconstipation Minimizingheavylifting.

Pelvicfloormuscletraining

First-linetreatmentforstage1and2prolapse Offeratrialofsupervisedtrainingforatleast3months Itshouldincludeeightcontractions,sustainedfor6–8seconds,performedthreetimesdaily.

Pessaries

Considervaginaloestrogeniftherearesignsofvaginalatrophybeforepessaryinsertion Explainthatmorethanonefittingmaybeneededandthatthepessaryshouldberemovedevery6 months to avoid complications which include bleeding, discharge, difficulty removing, and expulsion.

Surgicalmanagement

There are numerous surgical procedures available for the treatment of prolapse, e.g.

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